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STEP 4: POSTOPERATIVE CARE
Adherence to a postoperative colorectal clinical pathway ensures standardization of care.
Nasogastric decompression is not necessary unless vomiting and postoperative ileus or obstruction occurs.
Adequate pain control is achieved using patient-controlled algesia.
Stress ulcer prophylaxis, such as famotidine (Pepcid) 20 mg IV every 12 hours, should be used in patients with prior peptic ulcer disease (PUD), gastroesophageal reflux disease (GERD), or symptoms to suggest disease.
All patients should receive prophylaxis for deep venous thrombosis (DVT), using sequential compression devices while in bed and heparin 5000 U subcutaneously every 8 hours or enoxaparin 40 mg subcutaneously every morning. Dosing schedules according to PQRI quality measures may begin preoperatively, or, as we practice, within 24 hours from the operation after morning laboratory test results are back, to ensure there is no significant drop in hemoglobin level to suggest postoperative bleeding.
Adequate intravenous fluid should be administered with monitoring of urine output via urimeter on the Foley bag. The Foley catheter may be removed on postoperative day 1.
The diet may be limited to ice chips and sips of water in the postanesthesia care unit and on postoperative day 1. Return of bowel function is measured by the frequency and pitch of bowel sounds, lack of abdominal distention, and the patient’s subjective will to eat. A clear liquid diet may be offered as sips of clear liquids without carbonation and without a straw to minimize buildup of air in the intestine. This may be advanced ad lib as bowel function returns.
Early ambulation is crucial for aid in return of bowel function. Patients should be instructed to walk multiple times a day beginning on postoperative day 1.
The incision site should be checked on postoperative day 1 and daily thereafter to ensure absence of infection. Wicks should be removed before the patient leaves the hospital.
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STEP 5: PEARLS AND PITFALLS
Soft tissue infection can occur to varying degrees, with necrotizing fasciitis as the worst case scenario. The ostomy site should be loosely closed and meticulous attention paid to the appearance of the wound postoperatively. In addition, anastomotic leak may present in part as a soft tissue infection.
Wrapping a temporary ileostomy or colostomy with Seprafilm allows for easier takedown later. This consideration should be made during the initial surgery.
SELECTED REFERENCES
1. Zeng Q, Yu Z, You J, Zhang Q: Efficacy and safety of Seprafilm for preventing postoperative abdominal adhesion: Systematic review and meta-analysis. World J Surg 2007;31:2125-2131;2132 [discussion].
2. QualityNet: Site index. Available at www.qualitynet.org.
3. Itani KM, Wilson SE, Awad SS, et al: Ertapenem versus cefotetan prophylaxis in elective colorectal surgery. N Engl J Med 2006;355:2640-2651.
4. Beck DE, Opelka FG: Perioperative steroid use in colorectal patients: Results of a survey. Dis Colon Rectum 1996;39:995-999.
5. Law WL, Bailey HR, Max E, et al: Single-layer continuous colon and rectal anastomosis using monofilament absorbable suture (Maxon): Study of 500 cases. Dis Colon Rectum 1999;42:736-740.
RIGHT HEMICOLECTOMY
Celia Chao
STEP 1: SURGICAL ANATOMY
The right colon begins at the ileocecal valve, includes the right (ascending colon) hepatic flexure, and ends at the mid-transverse colon; the appendix is present at the inferior aspect of the cecum. The blood supply to this area comes from the superior mesenteric artery through its ileocolic, right colic, and right branches of the middle colic arteries. The lymphatics to the right colon follow its arterial blood supply. A minimum of 12 lymph nodes within the mesentery is considered an adequate resection when performing a right hemicolectomy for cancer.
STEP 2: PREOPERATIVE CONSIDERATIONS
Indications: Colon resection is performed for benign diseases, such as diverticulitis, ischemic colitis, volvulus, polyposis, bleeding from arteriovenous malformation, trauma, inflammatory bowel disease, and curative treatment or palliation of malignant tumors of the colon and rectum. The extent of resection is based on the vascular supply of the specific location of the tumor. Tumors at the hepatic flexure or on the proximal transverse colon can be resected with an extended right hemicolectomy, which involves additionally taking the blood supply and transverse colon to the left of the middle colic artery.
Preoperative planning: In clinical practice throughout North America, an adequate mechanical bowel preparation is generally considered desirable the day before surgical resection. Preoperatively, intravenous antibiotics must be administered before the skin incision. A preoperative dose of subcutaneous heparin (5000 U) or a low-molecular-weight heparin is recommended to prevent deep venous thrombosis. Before induction of general anesthesia, pneumatic compression boots are placed on both lower extremities and continued postoperatively until the patient ambulates on the first postoperative day.
Anesthesia: General anesthesia is used.
C H A P T E R 58 • Right Hemicolectomy |
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STEP 3: OPERATIVE STEPS
1.INCISION
A midline incision (Figure 58-1) is made, and a Thompson retractor is placed to retract the anterior abdominal wall and increase exposure in the region of the right colon.
Incision
FIGURE 58–1
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2. DISSECTION
A standard exploration of the intra-abdominal cavity is performed to determine the extent of disease and resectability. The peritoneal surface, liver, porta hepatis, mesenteric nodes, and ovaries are examined. The right colon is mobilized from its retroperitoneal attachments by incising the white line of Toldt (Figure 58-2).
The cecum and ascending colon are retracted medially, exposing the right ureter and gonadal vessels. Continuing superiorly along this retroperitoneal plane, the hepatocolic ligament is divided to release the hepatic flexure (Figure 58-3).
Posteriorly, the duodenum is identified and separated from the colon. The omentum is mobilized off the transverse colon by dissecting along an avascular plane (Figure 58-4).
Incision of white line of Toldt
C H A P T E R 58 • Right Hemicolectomy |
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Division of hepatocolic ligament
FIGURE 58–3
Dissection of omentum from transverse colon
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If the omentum is adherent or close to the tumor, that portion of the omentum can be removed en bloc with the resected colon. The points of transection of the terminal ileum and transverse colon are decided based on the mesenteric blood supply (Figure 58-5).
Using a gastrointestinal anastomosis (GIA) stapler, transect the terminal ileum 10 to 15 cm from the ileocecal valve for lesions involving the cecum and approximately 5 cm for lesions distal to the cecum (Figure 58-6).
The transverse colon is divided in similar fashion with the GIA stapler just to the right of the middle colic artery. The peritoneum to the mesentery is scored with electrocautery; the vessels, and not the surrounding fatty tissue, can be more easily clamped and tied. The mesentery corresponding to the points of resection are divided to the origins of the ileocolic and right colic arteries to ensure adequate removal of the node-bearing tissue in the mesentery.
Line of transection
Middle colic vessels
Right colic vessels
Ileocolic vessels
Ligation of distal ileomesenteric vascular arcade
C H A P T E R 58 • Right Hemicolectomy |
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Ends of divided transverse colon
GIA stapler used to divide ileum
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Creation of continuity between the terminal ileum and transverse colon can be performed using either a hand-sewn or a stapled technique. A standard end-to-end (Figures 58-7 through 58-10) or side-to-side anastomosis (Figures 58-11 and 58-12) are then performed.
Transverse colon
Posterior interrupted sutures
Two continuous running sutures
Ileum
Anterior running sutures
Lembert sutures
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